Psychiatry: Mood disorders

• Depression: Recognising Depression | Causes and Associations | Treating Less Severe Depression | Treating More Severe Depression | Choosing and Using Antidepressants | Antidepressant Side Effects and Safety | Stopping Antidepressants | Treatment-Resistant Depression | Psychotic Depression and Depressive Stupor
• Bipolar disorder: Recognising Bipolar Disorder | Treating Mania and Hypomania | Bipolar Depression | Lithium | Other Mood Stabilisers
• Other mood problems: Perinatal Mental Illness | Persistent, Seasonal and Premenstrual Mood Disorders | Grief and Prolonged Grief | Suicide and Self-harm in Adults
• Revision: Drug Reference Table | Spot the Diagnosis | Exam-style Scenarios | Key Points | Guidelines and Further Reading

😔 Mood disorders — depression is one of the commonest reasons for seeing a GP and a major cause of disability worldwide. Most people are treated in primary care with psychological therapy, medication or both. Bipolar disorder often starts with depression and is easily missed — always ask about past periods of high mood before starting an antidepressant. Lithium is highly effective but has a narrow therapeutic range.
Your four questions for every patient: How severe is the depression (and is there psychosis)? Has there ever been mania or hypomania? Is the person at risk of suicide or self-neglect? Is there a physical cause, a drug cause, or pregnancy to consider?

Recognising Depression

• Core symptoms (most of the day, nearly every day, for at least 2 weeks):
  • Low mood.
  • Loss of interest or pleasure (anhedonia).
• Other symptoms:
  • Low energy, tiredness.
  • Sleep change — early morning waking (typical), or sleeping too much.
  • Appetite and weight change.
  • Poor concentration and indecisiveness.
  • Feelings of worthlessness or guilt; low self-esteem.
  • Hopelessness about the future.
  • Psychomotor slowing or agitation.
  • Thoughts of death or suicide; self-harm.
  • Biological ("somatic") features — early morning waking, mood worse in the morning (diurnal variation), loss of appetite and weight, loss of libido, slowing.
• Screening — the Whooley questions: "During the last month, have you often been bothered by feeling down, depressed or hopeless?" and "...by having little interest or pleasure in doing things?"
• Severity — based on number and impact of symptoms; PHQ-9 (scores 0–27). NICE NG222 uses:
  • Less severe depression — PHQ-9 under 16 (includes "subthreshold" and mild).
  • More severe depression — PHQ-9 16 or more (moderate and severe).
• Differential diagnosis — bipolar depression, adjustment disorder, grief, dementia (pseudodementia in older people), hypothyroidism, anaemia, substance misuse, medication effects, psychotic disorders.
• Presentations to watch for — physical complaints (tiredness, pain), insomnia, older people (agitation, cognitive complaints), men (irritability, alcohol use), and people from cultures where mood isn't described directly.

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Causes and Associations

• Predisposing — family history, childhood adversity and abuse, female sex, personality traits (neuroticism), chronic illness, social disadvantage.
• Precipitating — loss (bereavement, relationship, job), stress, debt, physical illness, childbirth, substance use.
• Perpetuating — isolation, unemployment, ongoing stress, alcohol, chronic pain, poor sleep.
• Physical illnesses linked with depression — hypothyroidism, Cushing's, Addison's, diabetes, stroke, Parkinson's disease, MS, dementia, cancer (especially pancreatic), heart disease (post-MI), chronic pain, HIV.
• Drugs that can cause low mood — steroids, isotretinoin, interferon, levetiracetam, beta-blockers (debated), hormonal contraception (in some), finasteride, alcohol, cannabis, withdrawal from stimulants.
• Depression with physical illness — depression worsens outcomes (e.g. after MI); treat both.

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Treating Less Severe Depression

• General measures — explain the diagnosis; assess risk; advice on sleep, activity, alcohol; address social problems (debt, housing); support from family and friends.
• Active monitoring — if the person prefers to wait; review within 2–4 weeks.
• First-line treatments (NICE NG222 — choose with the person; roughly in order of cost-effectiveness):
  • Guided self-help (books or online, with support).
  • Group CBT or group behavioural activation.
  • Individual CBT or behavioural activation.
  • Group exercise.
  • Group mindfulness and meditation.
  • Interpersonal therapy (IPT).
  • SSRI — not routinely first-line for less severe depression unless the person prefers it.
  • Counselling; short-term psychodynamic therapy.
• Self-referral to NHS Talking Therapies.
• St John's wort — not recommended (variable strength; interactions with the contraceptive pill, warfarin, antiepileptics, SSRIs — serotonin syndrome).

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Treating More Severe Depression

• First-line options (NICE NG222):
  • Combination of individual CBT and an antidepressant — the most effective.
  • Individual CBT or behavioural activation alone.
  • An antidepressant alone (SSRI, SNRI, mirtazapine, or others).
  • Individual problem-solving, counselling, IPT, or short-term psychodynamic therapy.
  • Guided self-help (if other options are declined).
• Refer to specialist mental health services if — high risk of suicide, psychotic symptoms, severe self-neglect, treatment not working after two or more attempts, possible bipolar disorder, complex problems.
• Crisis or home treatment team, or admission, if the person is at significant risk.
• Ongoing care — continue the antidepressant for at least 6 months after remission; longer (often 2 years or more) if at high risk of relapse (previous episodes, residual symptoms, severe episodes); relapse-prevention therapy (CBT, mindfulness-based cognitive therapy).

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Choosing and Using Antidepressants

• Starting an antidepressant:
  • Discuss benefits, delay of 2–4 weeks before benefit, side effects, withdrawal symptoms if stopped suddenly, and the need to continue after feeling better.
  • Review within 2 weeks (within 1 week if aged 18–25 or at increased suicide risk); then every 2–4 weeks for the first 3 months.
  • If no response after 4 weeks at a therapeutic dose (or partial at 6–8 weeks), check adherence, increase the dose, or switch.
  • Prescribe small quantities if at risk of overdose.
• Choosing — previous response, side effect profile, other conditions (heart disease — sertraline; insomnia — mirtazapine), interactions, overdose risk, patient preference, pregnancy and breastfeeding (sertraline is commonly used).

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Antidepressant Side Effects and Safety

• Common SSRI side effects — nausea, diarrhoea, headache, anxiety and agitation in the first 1–2 weeks, insomnia, sweating, sexual dysfunction (can persist in a few after stopping), weight change.
• Increased suicidal thoughts — in the first weeks, especially under 25 — warn and review early.
• Hyponatraemia (SIADH) — especially older people, with diuretics; check sodium if drowsy or confused (check before and after starting in high-risk patients).
• Bleeding risk — SSRIs reduce platelet serotonin; GI bleeding with NSAIDs, aspirin or anticoagulants — consider a PPI or an alternative (mirtazapine).
• QT prolongation — citalopram, escitalopram, TCAs (ECG if cardiac risk).
• Switching to mania — in people with undiagnosed bipolar disorder (ask about past highs).
• Serotonin syndrome — with combinations: SSRIs or SNRIs plus MAOIs, tramadol, triptans, linezolid, St John's wort, MDMA, lithium, ondansetron (high doses) — agitation, sweating, fever, tremor, clonus and hyperreflexia, diarrhoea (see the Psychiatric Emergencies chapter).
• Falls in older people (sedation, hyponatraemia, postural hypotension).
• Overdose — TCAs and venlafaxine are more dangerous; SSRIs relatively safe alone.

⚠️ Safety Pearl: An older person on an SSRI who becomes confused, drowsy or falls should have their sodium checked — hyponatraemia from SIADH is common and easily missed.

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Stopping Antidepressants

• Withdrawal (discontinuation) symptoms — common if stopped suddenly or reduced quickly:
  • Dizziness, "brain zaps" (electric shock sensations), flu-like symptoms, nausea, sweating, anxiety, irritability, insomnia, vivid dreams, low mood.
  • Usually start within a few days; usually mild and short, but can be severe or prolonged (weeks to months) in some.
  • Worse with short half-life drugs — paroxetine and venlafaxine; least with fluoxetine.
• How to stop (NICE NG222):
  • Taper gradually, usually over weeks or months, by reducing the dose in steps (often by a proportion of the current dose — smaller steps at lower doses).
  • Use liquid forms or smaller tablet strengths for small steps.
  • If symptoms are troublesome — go back to the previous dose and reduce more slowly.
  • Distinguish withdrawal from relapse (relapse is usually later and more gradual).
• Switching — usually reduce one while starting the other ("cross-taper"); care when switching to or from MAOIs and fluoxetine (long washout — serotonin syndrome risk).

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Treatment-Resistant Depression

• Definition — no adequate response to two or more antidepressants at adequate dose and duration.
• First, review — diagnosis (bipolar, psychosis, personality factors), adherence, dose, physical causes (thyroid, anaemia), alcohol and drugs, ongoing stresses.
• Options (specialist advice):
  • Switch — to another SSRI, or another class (SNRI, mirtazapine).
  • Combine — e.g. an SSRI or SNRI plus mirtazapine.
  • Augment — with lithium or an antipsychotic (aripiprazole, quetiapine, olanzapine).
  • Add psychological therapy (CBT).
  • ECT — for severe, life-threatening or treatment-resistant depression.
  • rTMS; esketamine (not NICE-recommended); MAOIs (specialist).

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Psychotic Depression and Depressive Stupor

• Psychotic depression — severe depression with mood-congruent delusions or hallucinations:
  • Delusions of guilt, worthlessness, poverty, illness, or nihilism (believing organs are rotting or that they are dead — Cotard's syndrome).
  • Hallucinations — derogatory voices ("you're worthless"), smells of rotting.
  • High suicide risk.
  • Treatment — refer urgently to specialist services; antidepressant plus an antipsychotic; ECT if severe or not responding.
• Depressive stupor — severe slowing, mute, not eating or drinking, unresponsive — risk of dehydration, AKI, VTE and death; urgent admission, physical care, ECT; consider catatonia (lorazepam test).
• Depression in older people — may present with agitation, anxiety, physical complaints or cognitive impairment ("depressive pseudodementia"); higher suicide risk in older men; check for physical illness and medication effects.

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Recognising Bipolar Disorder

• What it is: Recurrent episodes of mania or hypomania and (usually) depression, with recovery between episodes. Lifetime risk about 1–2%; onset usually in the late teens to 20s; strong genetic component.
• Types:
  • Bipolar I — at least one episode of mania (most also have depression).
  • Bipolar II — hypomania and depression (no full mania); depressive episodes dominate.
  • Cyclothymia — persistent mood instability with mild highs and lows for at least 2 years.
  • Rapid cycling — four or more episodes a year.
• Mania (at least a week, or needing admission) and hypomania (at least 4 days, milder, no psychosis, less impairment):
  • Elevated, expansive or irritable mood.
  • Increased energy and activity; reduced need for sleep (feels rested after a few hours).
  • Pressured speech, flight of ideas, racing thoughts.
  • Grandiosity — inflated self-esteem; in mania, grandiose delusions (special powers, wealth, a mission).
  • Disinhibition — overspending, sexual disinhibition, reckless driving, risky business decisions.
  • Distractibility; poor insight.
  • Psychotic symptoms (in mania only).
• Mixed features — symptoms of mania and depression at the same time (high suicide risk).
• Before diagnosing — exclude drugs (steroids, levodopa, stimulants, cocaine, amphetamines, antidepressant-induced), hyperthyroidism, frontal lobe lesions, MS, HIV, delirium.
• Refer — anyone with suspected mania or hypomania to specialist mental health services (urgently if mania or risk).

💡 Clinical Pearl: Many people with bipolar disorder first present with depression. Before prescribing an antidepressant, ask about past periods of unusually high mood, little sleep or out-of-character behaviour — and about a family history of bipolar disorder.

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Treating Mania and Hypomania

• Assess risk — financial, sexual, driving, aggression, exhaustion, dehydration; capacity; MHA if needed; safeguarding of children.
• Stop antidepressants (taper if appropriate).
• Treatment (NICE CG185):
  • First-line — an antipsychotic: haloperidol, olanzapine, quetiapine or risperidone.
  • If not effective — try another antipsychotic.
  • Then — add lithium; if unsuitable, valproate (not for women and girls who could become pregnant, and new starts in under 55s only if two specialists agree).
  • If already on lithium — check the level and adjust; add an antipsychotic.
  • Benzodiazepine (short term) for agitation and sleep.
• Supportive — calm, low-stimulus environment; regular sleep; fluids and nutrition; limit access to money.
• After recovery — discuss long-term treatment (see Lithium); identify early warning signs (reduced sleep); relapse plan; psychological therapy.

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Bipolar Depression

• Often longer and more disabling than the manic episodes; high suicide risk.
• Treatment options (NICE CG185):
  • Fluoxetine with olanzapine, or quetiapine alone.
  • Olanzapine alone, or lamotrigine alone (slow titration).
  • Lurasidone (licensed in some countries; used by specialists).
  • Psychological therapy (CBT, IPT).
• Avoid antidepressant monotherapy — risk of switching to mania or rapid cycling; if used, always with an antimanic drug.
• If already on lithium — check the level; optimise.

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Lithium

• Uses — first-line long-term mood stabiliser in bipolar disorder (reduces relapse and suicide); augmentation in treatment-resistant depression; acute mania.
• Narrow therapeutic range — usual target 0.6–0.8 mmol/L (0.8–1.0 if relapsing on lower levels); blood sample 12 hours after the last dose.
• Before starting — U&E and eGFR, TFTs, calcium, weight and BMI, ECG (if cardiac risk), pregnancy test (if relevant), FBC.
• Monitoring (NICE):
  • Lithium level weekly after starting and after each dose change until stable.
  • Then every 3 months for the first year, then every 6 months (3-monthly for older people, interacting drugs, impaired kidney function, poor adherence).
  • U&E, eGFR, TFTs and calcium every 6 months; weight.
  • Carry a lithium card and record book; same brand always (different brands differ).
• Side effects:
  • Fine tremor, thirst and polyuria (nephrogenic diabetes insipidus), nausea, weight gain, metallic taste, acne and psoriasis flares.
  • Hypothyroidism (common — treat with levothyroxine; no need to stop lithium), goitre.
  • Hyperparathyroidism and hypercalcaemia.
  • Kidney damage — CKD with long-term use (monitor eGFR).
  • T-wave changes, sinus node dysfunction.
  • Pregnancy — small risk of heart defects (Ebstein's anomaly); specialist planning; levels change in pregnancy and fall after delivery (toxicity risk postpartum).
• Toxicity (usually over 1.5 mmol/L, but can occur at lower levels):
  • Early — coarse tremor, vomiting, diarrhoea, ataxia, slurred speech, drowsiness.
  • Severe — confusion, hyperreflexia, myoclonus, seizures, arrhythmias, coma, AKI.
  • Causes — dehydration (vomiting, diarrhoea, heat), AKI, overdose, interacting drugs.
  • Treatment — stop lithium; IV fluids (0.9% saline); monitor levels; haemodialysis if severe (see the Psychiatric Emergencies chapter).
• Interactions — drugs that raise lithium levels — NSAIDs, ACE inhibitors, ARBs, thiazide diuretics (and loop diuretics less so), metronidazole; low-salt diets and dehydration.
• Advice to patients — drink enough fluids (more in hot weather or illness), avoid big changes in salt intake, avoid over-the-counter NSAIDs (ibuprofen), stop and seek advice if vomiting or diarrhoea, know the symptoms of toxicity.
• Stopping — taper over at least 4 weeks (sudden stopping raises the risk of relapse into mania).

⚠️ Safety Pearl: A person on lithium who is started on ibuprofen, an ACE inhibitor or a thiazide, or who gets diarrhoea and vomiting, can become toxic within days. Coarse tremor, unsteadiness and confusion need an urgent lithium level and U&E.

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Other Mood Stabilisers

• Valproate:
  • Effective in mania and long-term treatment.
  • Highly teratogenic (neural tube defects, neurodevelopmental problems in about 30–40% of exposed children) — must not be used in women and girls of childbearing potential unless there is no alternative and a Pregnancy Prevention Programme is in place.
  • MHRA (2024) — new starts in anyone under 55 (men and women) only if two specialists independently agree there's no suitable alternative; men should be advised about contraception.
  • Side effects — weight gain, tremor, hair loss, liver toxicity, pancreatitis, thrombocytopenia, raised ammonia.
• Lamotrigine — prevents bipolar depression more than mania; slow titration to reduce the risk of Stevens–Johnson syndrome (stop if a rash appears); dose changes with valproate (halve) and the combined pill.
• Carbamazepine — second-line; enzyme inducer (reduces effect of contraceptive pill, warfarin and others); hyponatraemia, rash (HLA-B*1502 in Han Chinese and Thai people — SJS), agranulocytosis.
• Antipsychotics — olanzapine, quetiapine, aripiprazole and risperidone are used long term (alone or with lithium); metabolic monitoring.
• Long-term plan (NICE CG185) — lithium first-line; if not effective or tolerated — valproate (if suitable) or olanzapine or quetiapine; plus psychological therapy for bipolar disorder.

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Perinatal Mental Illness

• Baby blues — very common (up to 8 in 10): tearful, anxious, low or irritable on days 3–10 after birth; resolves within 2 weeks without treatment; reassure and support.
• Postnatal depression — about 1 in 10 mothers (fathers too); within the first year:
  • Low mood, anxiety, irritability, guilt about not coping, worries about the baby's health, sleep problems beyond those from caring for a baby, intrusive thoughts.
  • Screening — Whooley questions at booking and after birth; Edinburgh Postnatal Depression Scale.
  • Treatment — psychological therapy (CBT, IPT — prioritised for perinatal women); antidepressants if moderate to severe (sertraline is commonly used in breastfeeding — low levels in breast milk); health visitor and perinatal mental health team support.
• Postpartum (puerperal) psychosis — 1–2 per 1,000 births; a psychiatric emergency:
  • Usually starts within the first 2 weeks (often days) after birth.
  • Rapid onset of confusion, mania or mixed mood, delusions (often about the baby), hallucinations, severe insomnia, bizarre behaviour.
  • Risk factors — bipolar disorder (high risk — about 1 in 5) or a previous postpartum psychosis, family history, first baby, stopping mood stabilisers in pregnancy.
  • Risks — suicide and infanticide.
  • Urgent admission — ideally to a mother and baby unit; antipsychotics, mood stabilisers, ECT if severe; exclude organic causes (infection, thyroid, eclampsia, sodium).
• Planning before and during pregnancy — preconception advice for women with severe mental illness; avoid valproate; specialist review of lithium (continue in some with closer monitoring); avoid stopping medication suddenly; birth plan with the perinatal team.
• Other perinatal problems — anxiety, OCD (intrusive thoughts of harming the baby — distressing but not acted on), PTSD after traumatic birth, tokophobia (fear of childbirth).
• Maternal suicide is a leading cause of death in the year after pregnancy (MBRRACE-UK) — ask about it.

⚠️ Safety Pearl: A woman with bipolar disorder who has just given birth is at high risk of postpartum psychosis. New insomnia, confusion or strange beliefs in the first days after birth need same-day psychiatric assessment.

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Persistent, Seasonal and Premenstrual Mood Disorders

• Dysthymia (persistent depressive disorder) — chronic low-grade depression for 2 years or more; treat with psychological therapy and antidepressants (SSRIs).
• Cyclothymia — persistent instability of mood with mild highs and lows (2 years or more); may progress to bipolar disorder.
• Seasonal affective disorder — recurrent depression in autumn and winter, with oversleeping, overeating (carbohydrate craving) and weight gain; remits in spring. Treat as depression (CBT, SSRIs); light therapy.
• Premenstrual dysphoric disorder — severe mood symptoms (irritability, low mood, anxiety) in the luteal phase that resolve with menstruation; symptom diary for 2 cycles; SSRIs (continuous or luteal phase), combined pill (drospirenone), CBT; GnRH analogues (specialist).
• Adjustment disorder — see the Anxiety, Stress and Somatic chapter.

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Grief and Prolonged Grief

• Normal grief — sadness, yearning, crying, sleep and appetite change, guilt, anger, sense of the dead person's presence (brief hallucinations of the deceased's voice are common and normal). Comes in waves; gradually eases over months.
• Stages (not strictly in order) — shock and disbelief, yearning and searching, anger and guilt, despair, acceptance and reorganisation.
• Support — listening, information, practical help, bereavement services (e.g. Cruse); no medication needed for normal grief.
• Prolonged grief disorder (ICD-11) — intense longing or preoccupation with the deceased with emotional pain lasting over 6 months (well beyond cultural norms) and impairing functioning; grief-focused psychological therapy.
• Depression after bereavement — worthlessness, persistent suicidal thoughts, psychomotor slowing and severe functional loss suggest depression — treat it.
• Risk factors for complicated grief — sudden or traumatic death (suicide, homicide), death of a child, ambivalent or dependent relationship, previous mental illness, lack of support.

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Suicide and Self-harm in Adults

• Suicide — about 6,000–7,000 deaths a year in the UK; about three-quarters are men; highest rates in middle-aged men. Most people who die by suicide were not in contact with mental health services in the previous year.
• Risk factors — previous self-harm (the strongest), depression, bipolar disorder, schizophrenia, personality disorder, alcohol and drug misuse, chronic physical illness and pain, recent loss, debt, unemployment, social isolation, imprisonment, access to means, family history of suicide, recent discharge from a psychiatric ward.
• High-risk periods — the first weeks after discharge from inpatient psychiatric care (follow-up within 72 hours is the NHS standard), early in treatment, after a major loss.
• Self-harm in adults (NICE NG225):
  • Treat physical injury and poisoning; respect, dignity and compassion.
  • Psychosocial assessment by mental health (liaison) services before discharge where possible.
  • Don't use risk tools or scales to predict risk or allocate care.
  • Collaborative safety plan; means restriction (limit medicines supplied — e.g. paracetamol pack sizes).
  • Offer psychological therapy (CBT-informed, specifically for self-harm); treat underlying conditions.
  • Don't offer drug treatment specifically to reduce self-harm.
• Suicide prevention — national strategy (restricting means, safer prescribing, support after self-harm, bereavement support for people bereaved by suicide, safer media reporting).
• Supporting staff and families after a suicide — postvention support; Support After Suicide Partnership.

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Drug Reference Table

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Spot the Diagnosis

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Exam-style Scenarios

1. A 38-year-old woman has had low mood, poor sleep and loss of interest for 6 weeks. PHQ-9 is 18. She has no history of high mood and no suicidal plans.
Answer: More severe depression.

• Offer individual CBT combined with an antidepressant (e.g. sertraline), or either alone by preference.
• Review within 2 weeks; explain the delay in effect, side effects and withdrawal.
• Continue for at least 6 months after remission; safety plan and crisis contacts.

2. A 24-year-old man started citalopram a week ago and now says he feels more agitated and has had thoughts of suicide.
Answer: Early SSRI activation with increased suicidal thinking in a young adult.

• Assess risk urgently and make a safety plan; consider crisis team involvement.
• Review medication (dose reduction, switch, short-term support); ask about past manic symptoms.
• Close follow-up (weekly); small prescription quantities.

3. A 29-year-old woman with bipolar disorder on lithium wants to become pregnant.
Answer: Preconception planning with the perinatal mental health team.

• Discuss relapse risk if lithium stops versus a small risk of Ebstein's anomaly; many continue with closer monitoring.
• If continued — more frequent levels in pregnancy, fetal echo, and close monitoring after delivery (levels rise).
• Plan for high postpartum psychosis risk; avoid valproate.

4. A 52-year-old man on lithium has had diarrhoea for 3 days. He is unsteady, has a coarse tremor and is confused. Lithium level 2.4 mmol/L, creatinine raised.
Answer: Lithium toxicity with AKI.

• Stop lithium; IV 0.9% saline; monitor fluid balance, U&E and lithium levels; ECG.
• Discuss with the renal team — haemodialysis if severe neurological features or kidney failure.
• Seek advice from TOXBASE; review interacting drugs before restarting.

5. A 31-year-old woman, 6 days after her first baby, is not sleeping, talking rapidly and believes her baby has been swapped. She has a family history of bipolar disorder.
Answer: Postpartum psychosis.

• Psychiatric emergency — same-day assessment; admission to a mother and baby unit (MHA if needed).
• Exclude organic causes (infection, thyroid, pre-eclampsia, electrolytes, drugs).
• Antipsychotic, mood stabiliser, ECT if severe; ensure the baby's safety; support the partner.

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Key Points

• Depression: low mood and/or loss of interest for 2 weeks plus other symptoms; ask about suicide.
• Less severe depression (PHQ-9 under 16): guided self-help, group CBT or BA, exercise; antidepressants only if preferred.
• More severe depression: CBT plus an antidepressant is most effective.
• SSRIs first-line; sertraline in heart disease; citalopram prolongs QT.
• Review new antidepressants at 2 weeks (1 week if 18–25 or at risk); continue 6 months after remission.
• SSRIs: hyponatraemia in older people, GI bleeding with NSAIDs, serotonin syndrome with tramadol, triptans, linezolid, MAOIs.
• Taper antidepressants gradually; paroxetine and venlafaxine have the worst withdrawal.
• Psychotic depression: antidepressant plus antipsychotic; ECT if life-threatening.
• Always ask about past mania before starting an antidepressant.
• Mania: stop antidepressants; antipsychotic first; then add lithium (or valproate if suitable).
• Bipolar depression: quetiapine, olanzapine with fluoxetine, or lamotrigine — avoid antidepressants alone.
• Lithium: target 0.6–0.8 mmol/L at 12 hours; level weekly until stable, then 3-monthly, then 6-monthly; U&E, TFTs and calcium 6-monthly.
• NSAIDs, ACE inhibitors, ARBs, thiazides and dehydration cause lithium toxicity — coarse tremor, ataxia, confusion.
• Valproate: avoid in women who could become pregnant; two-specialist rule for new starts under 55.
• Baby blues: days 3–10, self-limiting. Postpartum psychosis: first 2 weeks, emergency — mother and baby unit.
• Follow up within 72 hours after discharge from psychiatric inpatient care.

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Guidelines and Further Reading

• NICE NG222: Depression in adults — treatment and management
• NICE CG91: Depression in adults with a chronic physical health problem
• NICE CG185: Bipolar disorder — assessment and management
• NICE CG192: Antenatal and postnatal mental health
• NICE NG225: Self-harm — assessment, management and preventing recurrence
• MHRA: Valproate — safety measures and the Pregnancy Prevention Programme
• NPSA / NHS England: Safer lithium therapy
• MBRRACE-UK: Saving Lives, Improving Mothers' Care (maternal mental health)
• Royal College of Psychiatrists: Stopping antidepressants (patient information)
• BNF — for current doses

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